NLMA Parental Leave Allowance
Report Form

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Note Employment Insurance (EI) recipients with no other source of income during the benefit period should submit the special version of the Report Form.

Instructions Submit this form regularly to receive benefits under the NLMA Parental Leave Allowance. Failure to submit in a timely manner (biweekly recommended) will result in a disruption of benefits. This form covers two weeks (first Monday to second Sunday) and will not be accepted before this period has passed nor before the birth/placement date; please submit additional forms if reporting more than two weeks. Note, you must already have submitted the separate Application Form and been approved to receive the allowance.



NLMA Number

First Report
(For this child)

Yes No

Final Report
(For this child)

Yes No

Report Start Date

(Cannot be earlier than Birth/Placement Date; must be a Monday; must have already passed; cannot be earlier than October 5, 2015)

Report End Date

(Must be a Sunday; must have already passed)

Report Duration

1 2

(To update information originally submitted on Application Form, OTHERWISE LEAVE BLANK)

Child Full Name

Birth/Placement Date
(Proof may be requested; DD/MM/YY)

Leave Start Date

Leave End Date

(Earned during reporting period, regardless when payment is received)


Week Amount (CAD)
Fee for Service
(Gross amount; FFS income earned, regardless of when payment received)

First Week

Second Week

(Gross amount; academic-related parental leave allowances are exempt)

First Week

Second Week

Employment Insurance (EI) Benefits
(Gross amount; $543 maximum benefit expected if salaried; waiting period/timing of benefits has no bearing)

First Week

Second Week

Other Employment Income
(Gross amount; rural retention bonuses are exempt)

First Week

Second Week




Assistance For assistance, please contact J. David Mitchell, Director, Administration & Membership at (709) 726-7424 (301), (800) 563-2003 (301) or

Newfoundland and Labrador Medical Association
164A MacDonald Dr., St. John's, NL, Canada, A1A 4B3
Telephone (709) 726-7424 | Toll Free (800) 563-2003 | Fax (709) 726-7525
E-mail | Web